Strengthening the Primary Care Pipeline

Recently, I had a vivid dream in which I and several family physician colleagues had gathered in a lecture hall to watch the results of the National Residency Match on a huge real-time video screen. On the right side of the screen were the names of all the graduating medical students; on the left was a smaller list of those matching to residency programs in Family Medicine. A bar graph positioned in between showed the overall percentage of our graduates matching into Family Medicine programs, which in previous years had been around 5 percent.

As the results began to trickle in, it looked like that pattern would continue. Then, an astounding thing happened. Student after student began appearing on the left side of the screen, and the percentage bar climbed higher and higher – to 10%, then 15%, then 20%. Everyone began cheering and clapping wildly, as if we were watching the election returns for a victorious Presidential candidate. When the last student’s name finally appeared on the screen, the bar stood at just short of 50 percent, a higher Family Medicine match rate than any school in the nation!

Alas, I soon woke to realize that it was only a dream. But this dream got me thinking about what it would take to increase the percentage of primary care physicians to 50 percent, which is the typical ratio in most high-functioning national health systems. The obstacles are formidable, with financial considerations being perhaps the greatest challenge. Consider these figures from a solicitation letter for scholarship donations to my medical school alma mater: “Among the 155 members of the Class of 2008, 78 percent graduated with an average debt load of nearly $143,000. 18 percent graduated with a debt load that exceeded $200,000.” These figures are hardly atypical for most private (and some public) medical schools. Given these grim numbers, it’s a wonder that any medical students choose careers in primary care, with the lowest-paid specialties being general pediatrics, family medicine, and general internal medicine.

In a 2008 letter published in the Journal of the American Medical Association, family physician-educator Mark Ebell, MD, MS demonstrated a near-linear association between median income and the percentage of U.S. senior medical students who entered a medical speciality – put simply, students go where the money is. And given their increasingly staggering debt loads, who can really blame them?

A few years ago, a group of family physicians and health policy analysts at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care did an exhaustive study of the factors that affect medical students’ selection of careers. In their exceptional report, subtitled “What Influences Medical Student and Resident Choices?” Dr. Robert L. Phillips, Jr. and colleagues made several evidence-based recommendations for policymakers that bear repeating loudly in the White House and halls of Congress as the date approaches when 32 million additional Americans will be newly covered by health insurance and seeking primary care doctors.

1. Create more opportunities for students and young physicians to trade debt for service.

2. Reduce or resolve disparities in physician income.

3. Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice, and care of the underserved.

4. Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.

5. Shift substantially more training of medical students and residents to community, rural, and underserved settings.

6. Support primary care departments and residency programs and their roles in teaching and mentoring trainees.

7. Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act. (Title VII is a small, little known federal program that supports primary care residency training, but has been severely shrunk by budget cuts during the past decade.)

8. Study how to make rural areas more likely practice options, especially for women physicians. (The report found that “female physicians are twice as likely as men to choose primary care but half as likely to practice in rural areas.”)

9. New medical schools should be public with preference for rural locations. (One recently established medical school, The Commonwealth Medical College in Scranton, PA, exemplifies how this recommendation will encourage students to pursue primary care careers.)

The 2010 Affordable Care Act contained some provisions that will modestly benefit primary care physicians, but much more work and legislation is needed if my dream of a robust primary care pipeline is to become reality at medical schools throughout the U.S.